AZ Guy, at this point, your only action is to heal from the surgery and get your strength back. They can't do anything for a while--a couple of months at least. At that point, the decision of what (and when) to do additional treatment will be determined by your PSA and other tests that may be indicated.

Yes, it sucks that you got a nasty upgrade. It may be that you're one of the lucky ones that will still get to non-detectable and stay there. Or maybe not. No one can really say today how it will play out. That sucks too, but it is what it is.

I had one small, one millimetre, surgical margin. I have since seen one scientific paper which found no difference in outcome for a single very small positive margin versus no margin at all. (Of course next week another paper may come out saying the opposite). But it seems to be agreed that lots of positive margins or a large positive margin is less desirable than no positive margin at all. So, you could ask for more details about the magnitude of the positive margins. That said, no one is ever completely out of the woods. A few people with negligible cancer suffer recurrence. Others in which cancer had spread to lymph nodes and seminal vesicles never see recurrence. It seems to be an issue of the probabilities of recurrence increasing with greater spread. But nothing seems to be 100% in either direction.

If you really want to get a better handle on your status, in a few months have an ultrasensitive PSA test done. It seems that recurrence is very rare if that number comes out below 0.003. Some studies have found that below 0.05 has a large proportion of benign prognoses. Mine was 0.009, which seems to be associated with a 15% risk of recurrence within five years. But again, different studies done on different groups of patients come out with differing results.

Obviously, the less the cancer seems to have spread the better the outlook. And bear in mind the following: After PSA rises again above 0.2 (if it ever does) on average it takes 8 to 10 years before metastasis can be detected in bone. And after that, people live on average about five more years. This is why, while 60% of men in their 70s HAVE prostate cancer - although the vast majority never know about it - only ~3% of men die from it, simply because, at that age, they die from something else first. It is MUCH MUCH better to have prostate cancer than almost any other type of cancer.

Hi AZ guy: My previous post was, of course, addressed to you. So is this one. You might want to take a look at some of the data here:

https://seer.cancer.gov/statfacts/html/prost.html

There is no more authoritative source than the above. It is the US National Institutes of Health department responsible for cancer - The National Cancer Institute. First of all note that of people diagnosed with prostate cancer 98.6% live at least five years. In addition, note in the table further down that page, that while it is estmated that in 2017 161,360 people will be diagnosed with the disease, 26,730 will die from it. Think about what this means: only 16.6% of people who are diagnosed with it will die from it. That percentage is almost identical to that for breast cancer.

There is a lot more data there that will be of interest. But the main message is that for most people the prospects are surprisingly encouraging.

"In addition, note in the table further down that page, that while it is estmated that in 2017 161,360 people will be diagnosed with the disease, 26,730 will die from it. Think about what this means: only 16.6% of people who are diagnosed with it will die from it."

I know I'm a little late coming to this thread, but I wanted to put a more positive spin on the above. Mortality rates per 1,000 are dropping for prostate cancer. It is being diagnosed earlier, and treatment is getting better. Most of the 26,730 dying from PC this year were diagnosed 5, 10, or 15 years ago, if not more. The percentage of the 161,360 diagnosed this year who die from PC will be much lower.

Tall Allen said...You didn't have the kind of MRI that is used to detect high grade cancer for active surveillance. But if you were headed for surgery anyway, you wouldn't need one.

Ask your pathologist for the size and grade at the margin - it might turn out later to be useful.

Allen, Although his report was rather brief and didn't say "mp MRI" he did seem to have one though. As you know, a mp MRI consists of T2WI, DWI, DCE and MRSI done in sequence. As it was a 3T machine, there was no need for an endorectal coil.

From his report:

"The normally hyperintense peripheral zone is heterogeneous with nonspecific multifocal areas of intermediate to low signal." seems to indicate T2WI

Weightloss- I think you are right. The normal MRI is T1 or T2 which, as you say would account for only the first statement. They are often done with and without contrast. But "restricted diffusion" is probably from a DWI. You are right that MRS is seldom done as part of mpMRIs. The lesson is that even the best mpMRIs will sometimes have false negatives for high grade cancer, and that TRUS biopsies often miss significant cancer. IMHO, AS candidates should always have a confirmatory biopsy within a year of the first biopsy, template mapping if they can get it, before "officially" being on AS. mpMRI alone without a biopsy is not reliable enough to confirm candidacy.

What I was referring to when I wrote "Small size/focal and low grade at the margin are mitigating factors." was in direct response to the OPs question: "Does anyone know whether there are mitigating factors for positive margins?" The comment had nothing to do with the tumor size.Allen - not an MD •PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement•SBRT 9 yr onc. results •SBRT 7 yr QOL results•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEsmy PC blog

I was able to use Best Doctors again as a service through my Employer. They did their own pathology at Mass General in Boston. They state the Gleason is 3+4 vs the 4+3 at the original post-op pathology. Mass General also states that the tumor involved <10% of the Prostate. The positive margin is confirmed. So it still comes down to watching the PSA and doing SRT if required.Age 49DX 2/17: G6 2/12 cores <5% in each; one lobePSA 6.6 (doubling actual 3.3 due to Finasteride use)RALP 8/17pT2c R1Gleason 7 (4+3) Margin Positive-ECE; -SVI; +PI

Your case seems very similar to mine, just age is different. I suggest an ultrasensitive PSA test periodically. My recent result - nine months after surgery - came in at 0.009. That is a little ambiguous as I still have not been able to determine if that means "undetectable" meaning less than 0.01 (which is how some test assays work), or if it means "the test measures below 0.009 and yours was calculated to be 0.009, specifically." If/when I get a response to my inquiries I will post, jftr.Age at diagnosis=74; PSA=6.8; %fPSA=7.5 (OUCH!) // Biopsy: 4+3; 2% // Surgery Oct 2016: pathology: 3+4; 8%; both sides; one 1 mm positive margin // fully continent in 30 days; but ED still at 10 months // usPSA Aug 2017=0.009 // SFSG!

halbert said...AZ guy, I, also, had a post surgery upgrade...not as much as you (I went from G6 on one side to G3+4 in all 4 quadrants). The key for you is to recuperate from the surgery and see what your PSA is in 3 months. Seriously, 3 months. Your doc may do a PSA at 6 weeks, but it's not definitive till 3 months. In the meantime, walk, eat well, do your kegals, and get back in shape.

Halbet, did you change labs between 8/30/16 and <0.04 and 2/15/17: <0.006? Of course, I realize <.04 could also be < .006, but that is possibly a huge drop, depending on whet the actual <.04 was, which could have been .03(or of course much lower). Or maybe your doc or other lab simply got new machines. But man, that is a low #!

AZ Guy, lets face it, we are dealing with possibly microscopic cancer cells(unless the needle got lucky and happened to stick right into the middle of a mass/tumor), and it is not difficult to miss a bunch of higher Gleason cells. We are probably lucky that they manage to more often than not hit the bad areas with our highest Gleason, or even hit a cancerous spot at all. Some of us are down graded, but not a few of us are up graded. The Bx is just a crap shoot, ore or less. On the bright side, one reason(certainly not the only) a bunch of us decide to have the surgery is to get that path report, just in case of a situation like yours exists. You and I both got news we didn't want, but at least we know. Hang in there Brother!PSA 10.9 ~112013 Bx on 112013 at age ~65yrs, with 5 of 12 pos with one G9(5+4), 1 PNI, T2B.RALP with lymph nodes at Vanderbilt 021914. (nodes clear, SV+, G9 down graded to 4+5, cut wide, but 1 tiny foci right at the edge of margin ) Pros. 106.7 gms!At 15 months, not wearing a pad most days, mostly dry PSA

Thanks for asking halbert- my recovery has been great really. I do get a dribble surprise now and then and it serves mostly as a reminder that I'm still in recovery. No ED. I'm taking Cialis every third day but think I will go to once a week. I do get Climacturia but think its getting better. I need to be sure to go to the bathroom sitting down, not standing, prior to sex. That seems to better empty the bladder.Age 49DX 2/17: G6 2/12 cores <5% in each; one lobePSA 6.6 (doubling actual 3.3 due to Finasteride use)RALP 8/17pT2c R1Gleason 7 (4+3) Margin Positive-ECE; -SVI; +PI

So spent the better part of the evening feeling sorry for myself. It was hard to tell the wife but with the positive margins its not the biggest surprise in the world. I have an appointment scheduled with Mayo Clinic RO for Wednesday next week. Appointment with my surgeon is scheduled for the end of this month but I suppose its time to say goodbye to him. My recovery has been excellent as I have no ED and seem to have my continence back (just seems like the bladder volume is less than before). At Mayo Clinic we'll go through my case and I've seen a great list of questions on this site to ask about. I think I'm good to go with SRT as soon as it makes sense. Looks like the battle continues....Age 49DX 2/17: G6 2/12 cores <5% in each; one lobePSA 6.6 (doubling actual 3.3 due to Finasteride use)RALP 8/17pT2c R1Gleason 7 (4+3) (Revised to 3+4 by Mass General)Margin Positive-ECE; -SVI; +PITumor <10% of glandPSA .4 10/17

Sorry to hear about the PSA - not what you wanted. Likely they can start SRT almost anytime. Maybe give another month or so for healing. Even if you decide to start SRT, it can take a few weeks to get things setup before they start treatment.

Sorry about that news, but as you said it wasn't necessarily surprising. The good news is that SRT should have an excellent chance of killing off any stray cells in the area. And anecdotally, there's been several stories here of SRT guys that have sailed through it. I'm sure if you post about getting ready for that, they'll give you lots of good feedback.

Here's hoping your next psa check will be non detectable! At the mayo in MN the RO wanted to wait at least 6 months before starting SRT for healing but we started with Lupron and then in 2 months will start SRT.

Actually, I decided, I've done so in the past, also ran a 5k to honor Movember, with my daughter. But this year, I've been growing my hair out (back to my "yout(h)", and it might look pretty unprofessional with a fuzzy stache. Normally I wouldn't care, but I've got a ton of client appointments in the next few weeks, that I need to get done in advance of heading down your way for the winter.